Health Assessment Final Flashcards
The number of muscle fibers is determined in utero we are born with the # of muscle fibers we will have for life over time the muscle fibers lengthen
When is bone growth completed and the peak bone mass achieved? Why is this important
Bone growth is completed at 20 years old but peak bone mass is achieved at 35 years old.
Having a balanced diet is essential, crash diets are bad. You are building the strength of the bones during this time esp for menopause and later years.
The balanced diet and increased calcium will decrease the chance of osteopenia, osteoporosis and fractures
How does being pregnancy affect the MS system?
Increase mobility of pelvic joint
Lordosis of spine (inward forward curvature) Waddle gait
Lower back pain
Muscle cramps
Increased fluids increase risk of carpal tunnel syndrome
How is the MS system of the older adult affected?
Alteration of the equilibrium between bone deposition and bone reabsorption results in Loss of bone density esp vertebrae and long bones
Higher risk of fx
Deterioration of joint cartilage
Decreased mobility
Muscle mass decreases
Axial Skeleton
Appendicular Skeleton
HUMAN
SKELETON
AP VIEWS
Skeletal muscles from anterior and posterior views.
Articular Structures
include joint capsule and articular cartilage, synovium and synovial fluid, intra-articular ligaments, and juxta-articular bone
Extra-articular structures:
include periarticular ligaments, tendons, bursae, muscle, fascia, bone, nerve, and overlying skin
Ligaments connect
Bone to Bone
Tendons Connect
Muscle to Bone
Synovial Joints
Freely movable
•Freely moving articulations containing ligaments and cartilage covering the ends of the opposing bones that are enclosed by a fibrous capsule
·eg: Knee, shoulder
•Synovial membranes line the joints and secrete the serous lubricating synovial fluid
MOST JOINTS ARE SYNOVIAL
Cartilaginous Joints
◦Slightly movable
◦
·eg: Vertebrae
Fibrous Joints
◦Immovable
◦
·eg: Skull sutures
Synovial Joint
Spheroidal
(ball and socket)
Type of Joint: Convex
surface in
concave cavity
Articular Shape: Wide-ranging flexion, extension, abduction, adduction, rotation, circumduction
Ex: Shoulder, hip
Synovial Joint
Hindge
Articular Joint: Flat, planar
Movement: Motion in one plane; flexion, extension
Ex: Interphalangeal joints of the hand and foot; elbow
Synovial Joints
Condylar
Articular Shape: Convex or concave
Movement: Movement of two articulating surfaces
not dissociable
Ex: Knee; temporomandibular joint
Bursae
develop in the spaces of connective tissue between tendons, ligaments, and bones to promote ease of motion at points where friction would occur
Wrist
(Radiocarpal Joint)
•Articulations of:
- •Radius and carpal bones
- •Proximal and distal row of carpal bones
- •Articular disc, ulna and carpal bones
Flexion and extension
Rotational movement
Hand
Articulation of:
- Carpals and metacarpals
- Metacarpals and proximal phalanges
- Middle and distal phalanges
Forearm
Articulation of:
- Articulations between radius and ulna at both proximal and distal locations
- Pronation and supination
Elbow
- Articulation of humerus, radius, and ulna
- Enclosed in a single synovial cavity
- Ligaments of the radius and ulna protecting the joint
- Bursa lies between olecranon and the skin
- Hinge joint permitting movement in one plane (flexion and extension)
Shoulder
(Glenohumeral joint)
- Articulation between the humerus and the glenoid fossa of scapula
- Ball-and-socket joint that permits movement of the humerus in many axes
- Acromion and coracoid processes and ligaments between them form arch surrounding and protecting joint
What are the shoulder and position of the humeral head stabilized by
Rotator cuff
What Muscles and their tendons comprise the rotator cuff
Supraspinatus
Infraspinatus
Teres minor
Subscapularis
Acromioclavicular Joint
•Articulation between the acromion process and the clavicle
•Sternoclavicular joint
Articulation between the manubrium of sternum and clavicle
•Temporomandibular joint (TMJ)
- Articulation between the mandible and temporal bone in the cranium
- Hinge action opens and closes mouth
- Gliding action permits lateral movement, protrusion, and retraction of the mandible
What vertebrae comprise the spine?
•Spine
- •Cervical vertebrae
- •Thoracic vertebrae
- •Lumbar vertebrae
- •Sacral vertebrae
Fibrocartilaginous disks separate vertebrae and are found….
Everywhere but the sacral vertebrae
Each disk has a ________ of __________ that cushions the vertebral bodies
Nucleus of fibrogelatinous
Vertebrae form a series of
joints that glide slightly over each other’s surfaces
Which vertebrae are the most mobile?
Cervical
Flexion and extension occur between the _____ and ______. Rotation occurs between _______ and _______
Flexion and extension occur between the skull and C1; rotation occurs between C1 and C2
_______ vertebrae are fused and, with the coccyx form the posterior portion of the pelvis.
Sacral
Hip joint
- Articulation between the acetabulum and the femur
- Ball-and-socket joint, permitting movement of the femur on many axes
- Three strong ligaments support joint
- Three bursae reduce friction in the hip
Knee
- Articulation of the femur, tibia, and patella
- Hinge joint, permitting movement (flexion and extension) between the femur and tibia on one plane
- Articulation of the femur, tibia, and patella
- Fibrocartilaginous disks (medial and lateral menisci) cushion the tibia and femur and are attached to the tibia and the joint capsule
What gives medial and lateral stability to the knee
Collateral ligaments
What adds anterior and posterior stability to the knee
•Two cruciate ligaments cross obliquely within the knee, adding anterior and posterior stability
__________ ___________ separates the patella, quadriceps tendon, and muscle from the femur
The suprapatellar bursa separates the patella, quadriceps tendon, and muscle from the femur
Ankle
(tibiotalar joint)
- Articulation of the tibia, fibula, and talus
- Hinge joint that permits flexion and extension (dorsiflexion and plantar flexion) in one plane
- Additional joints in the ankle, the talocalcaneal joint (subtalar) and transverse tarsal joint, permit it to pivot or rotate (pronation and supination)
Foot
- Articulations of the foot between the tarsals and metatarsals, the metatarsal and proximal phalanges, and the middle and distal phalanges
- Flexion and extension
MS system
Infants and children
- Long bones increase in length and thickness throughout childhood
- Cartilage in smaller bones ossifies
- Ligaments are stronger than bones until adolescence
- •Fractures common
- Muscle fibers lengthen
- Skeletal system grows
MS system
Adolescents
•Rapid growth in puberty results in:
- •Decreased strength in epiphyses
- •Increased risk for injury
- Bone growth completed about age 20
- Peak bone mass achieved at age 35
Common or Concerning Symptoms
MS System
Low back pain
Joint pain, stiffness, swelling, redness, Decrease ROM, trauma
Muscle pain (Cramp) or weakness
Inflammatory or infectious joint pain
Joint pain with systemic features such as fever, chills, rash, anorexia, weight loss, weakness
Joint pain with symptoms from other organ systems
Approach to Musculoskeletal Complaints
Algorithm for Low Backpain
What if the physical examination sequence for MS?
- Observation:
- Palpation
- AROM (active Range of Motion) if abnormal PROM (Passive ROM)
- Muscle strength (observe during AROM, and against resistance)
Physical Exam of Musculoskeletal Assessment of a Joint pathology
- If the joint is painful assess it last.
- So first assess joint on the opposite side if available
- Then proximal and distal joints on the same side
- Finally the painful/pathologic joint
- •For instance: Left elbow pain
- •Assess right elbow
- •Assess left shoulder and wrist
- •Assess Left elbow and contrast your findings with your assessment from the right elbow
Names of different movements
Active / Passive ROM
What to identify during the inspection of muscles?
- Bilateral symmetry
- Hypertrophy
- Atrophy
- Fasciculations
- Spasms
Goniometer use
Use a gonimeter to determine ROM where there is an increased or decreased ROM
Active ROM and passive ROM would be equal in ______ joints
contralateral
How is muscle strength graded?
•Graded 0 (no voluntary contraction) to 5 (full muscle strength)
- •Weakness may result from:
- •Disuse atrophy
- •Pain
- •Fatigue
- •Overstretching
Examination Muscle Strength
Grade
Level of Function
0 - No movement
1 - Trace movement
2 - Full passive range of motion
3 - Full range of motion against gravity, no resistance
4 - Full range of motion with resistance, though weak
5 - Full range of motion, full strength
What do you access for TMJ
- Observation for abnormalities
- Palpate
- •Pain
- •Crepitus, locking, and popping
•Assess ROM
- •Open and close
- •Lateral movement
- •Protrusion and contraction
- •Assess muscle strength
- •Temporalis
- •Masseter
What do you access for cervical spine?
Picture is muscle strength
•Inspect
- •Head alignment
- •Symmetry of muscles and skinfolds
•Palpate
- •Tone
- •Symmetry
- •Tenderness
- •Spasm
Picture is AROM
Cervical Spine
A. Normal
B. Scoliosis
C. Kyphosis
D. Lordosis
Scoliosis
Types of Scoliosis
·Congenital
·Neuromuscular
·Idiopathic
Thoraco-lumbar Scoliosis is more common in what population?
Thoraco-lumbar scoliosis is more common in peds and younger adults
Lumbar scoliosis is more common in what population?
Lumbar scoliosis more common in middle age and older adults
Flexion - Hyperextension
What is the Cervical Spine: Spurling Test
- Passively extend and rotate the patient’s neck to the affected side. Slowly start applying axial pressure by pressing down on the top of the patient’s head
- Radicular pain extending down the arm on the same side as the test is considered a positive test.
Thoracic Spine: Straight Leg Raise
Identify lumbar radiculopathy
Indicative of disc herniation, sciatica, nerve impingement
- Have the patient lie supine. Lift one leg at a time to 90 degrees or as far as the patient can tolerate. Place your other hand on the knee to ensure full knee extension
- The test is considered positive if there is pain between 30 and 70 degrees of hip flexion that radiates below the knee. To further confirm neurologic etiology, slightly lower the leg and dorsiflex the foot; this will often also reproduce the radicular symptoms.
Femoral Stretch Test
Used to detect inflammation on the nerve root at the L1, L2, L3, and sometimes L4 level
- Have the patient lie prone and extend the hip
- No pain is expected
- The presence of pain on extension is a positive sign of nerve root irritation
Apley Scratch Test
The patient attempts to touch the opposite scapula
1) Testing abduction and external rotation
2) Testing adduction and internal rotation
What to INSPECT and PALPATE the Shoulders for:
INSPECT - Size, Symmetry, Contour, Dislocation or winging of the scapula
PALPATE - Joints, Muscles
Examination of the Shoulder
Acromioclavicular joint (Crossover)
Localized tenderness or pain suggests inflammation or arthritis
What does the drop arm test detect?
Detects tears in the rotator cuff, namely supraspinatus
Drop arm test
Have the patient abduct the shoulder to 90 degrees
Instruct pt to slowly lower arm
POSITIVE test if the arm drops around 90 deg abduction, indicating a tear in the supraspinatus
Abduction above the shoulder from 90-120’ reflects deltoid
If the patient is unable to perform this motion, the examiner can hold the humerus at 90 degrees of abduction and apply slight pressure to the distal forearm. If the patient’s arm falls to the side, this also indicates a rotator cuff dysfx.
Supraspinatus: Empty Can Test
Connects the top of the scapula to the humerus
Contraction allows the shoulder to abduct
Most commonly damaged rotator cuff muscles
Positive = pain and sometimes weakness indicative of Supraspinatus tear, impingement or nerve damage
Neer Test
- identify supraspinatus impingement
- While stabilizing the patient’s scapula, passively forward flex the arm while the arm is in the pronated position
- Pain and apprehension are considered positive tests.
External rotator cuff test (test for infraspinatus and teres minor injuries)
- their shoulders, keeping both elbows bent at 90 degrees.
- Place your hands on the outside of their forearms.
- Direct them to push their arms outward (externally rotate) while you resist.
Interpretation: weakness and/or pain.
ROM for Elbows
- Flexion: expect 160 degrees
- Extension: expect 180 degrees
- Pronation: expect 90 degrees
- Supination: expect 90 degrees
Lateral Epicondylitis
Tennis Elbow
- Lateral epicondylitis ( Tennis Elbow)
- Gradual onset of pain outside ( lateral portion of the elbow)
- At time radiate to forearms
- Pain worsened with twisting or grasping movements
Opening a jar, shaking hands
Cozen’s test: With the elbow stabilized and the hand pronated and in a fist, have the patient extend their wrist against resistance.
Pain over the lateral epicondyle is considered a positive test.radial
Medial Epicondylitis
Golfers Elbow
- Gradual onset of pain inside ( medial ) aspect of the elbow). AKA funny bone
- Golfer elbow test:
- with the elbow stabilized, have the patient supinate their hand and close their fist. Next, have the patient flex their wrist against resistance.
- Pain over the medial epicondyle is considered a positive test.
Assess ROM for Hands and Wrists
- Flexion of fingers: expect 90 degrees
- Hyperextension of fingers: expect 30 degrees
- Flexion of wrist: expect 90 degrees
- Hyperextension of wrist: expect 70 degrees
- Rotation of hand: expect radial motion of 20 degrees, ulnar motion of 55 degrees
Carpal Tunnel Syndrome
◦Pain or numbness of the thumb, index, middle finger especially at night
◦Hand weakness during tasks
◦Weak abduction of the thumb
Risk factors:
- ◦Repetitive injury
- ◦Work related
- ◦Diabetes, hypothyroidism, and
Arthritis, pregnancy, High BMI,
Hypocalcemia
Tinel’s Sign
Tinel’s sign: tingling with tapping over the median nerve as it enters the carpal tunnel
Aching and numbness = positive sign
Phalen’s Sign
Phalen’s sign: numbness or tingling with pressing
backs of hands together in acute
flexion for 60 seconds
Numbness and tingling within 60 seconds = positive sign
De Quervain’s Syndrome
- Gradually worsening pain along the radial aspect of the thumb and wrist painful condition due to stenosis of the tendon sheath in the 1st dorsal compartment of the radial aspect of the wrist.
- Repetitive motions of the wrist and/or thumb result in microtrauma, metaplastic thickening of the tendons (EPB, APL), and narrowing of the surrounding tendon sheath.
- Increased risk in women 30-50, pregnancy, AA, PMH with RA, repetitive activities (golf, fly fishing, racquet, rowing, bicycle, video game, text messages)
Finkelstein Test
De Quervain’s Syndrome
- Finkelstein test identifies De Quervain’s syndrome
- With the forearm stabilized, have the patient grasp their thumb in their fist, then perform ulnar deviation of the hand
- Pain over the tendons is considered a positive test. Be sure to slowly deviate the hand, as this test, when positive, can be exquisitely painful.
Osteoarthritis
Has Heberden’s Nodes & Bouchards nodes that can also be present in RA and psoriatic arthritic
Heberden’s nodes
Osteoarthritis
Heberden’s nodes are hard or bony swellings that can develop in the distal interphalangeal joints (DIP)
Bouchard’s nodes
Osteoarthritis
Bouchard’s nodes are hard, bony outgrowths or gelatinous cysts on the proximal interphalangeal joints (PIP)
Rheumatoid Arthritis
Rheumatoid arthritis
It may begin any time in life.
Onset: Relatively rapid, over weeks to months
Joints are painful, swollen, and stiff.
It often affects small and large joints on both sides of the body (symmetrical), such as both hands, both wrists or elbows, or the balls of both feet.
**Morning stiffness usually lasts longer than 1 hour.
Frequent fatigue and a general feeling of being ill are present.
Dupuytren contracture.
- •Dupuytren’s contracture is a progressive nodularity and flexion contracture of the palmar fascia and digital flexors in the hand
- • slow onset over years and is usually seen in people over the age of 50. can lead to flexion contractures of the MCP and PIP joints
- •Risk factors:
Tobacco, alcohol, and diabetes are all risk
Inspect hips for:
•Inspect
- Symmetry
- Size
- Gluteal folds
ROM for HIPS
ROM Hip Knees
HIP: FABER test
Identifies hip flexor, sacroiliac, or hip intra-articular pathology. FABER stands for Flexion, ABduction, and External Rotation
With the patient supine, have them flex, abduct, and externally rotate the hip until the ankle rests upon the contralateral knee. Then, apply downward pressure, moving the knee closer to the table
Pain or decreased range of motion is considered a positive test.
HIP: FADIR TEST
FADIR TEST
The anterior impingement test or FADIR (Flexion ADDuction Internal Rotation) test is performed by flexing the hip to 90 degrees, adducting across the midline, and maximally internally rotating the hip
Ballottment
Medical sign which indicates increased fluid in the suprapatellar pouch over the patella at the knee joint. So test for knee effusion. To test ballottement the examiner would apply downward pressure towards the foot with one hand, while pushing the patella backwards against the femur with one finger of the opposite hand.
McMurray test
Identifies meniscus pathology mostly tear to lateral or medial meniscus
Pain or clicking over the medial or lateral joint lines is considered a positive test.
ROM Feet/Ankle
Plantar Fasciitis / Flat Feet
Clubfoot
- congenital condition where the forefoot is adducted, while the heel is in varus
- Early treatment will include casting and bracing, with surgery becoming an option around month 3 or 4, though it can be delayed if necessary.
Gout
- Gout is an inflammatory arthritis characterized by deposition of monosodium urate
- crystals that accumulate in joints and soft tissues, resulting in acute and chronic arthritis, soft-tissue masses called toph
Classic presentation of acute gouty arthritis:
- Intense pain and tenderness in the 1st metatarsophalangeal joint (podagra)
- Can occur in the midtarsal, ankle, or knee joints
- Joint may be swollen, warm, and erythematous.
- Often awakens patients from sleep due to an intolerance to contact with clothing or bed sheets
- There is a rapid onset of intense pain, often beginning in the early morning and progressing rapidly over 12 to 24 hours.
- In the absence of treatment, flares can last up to 10 days.
- Fever can be present.
Redness, swelling, decreased ROM and acute tenderness to the affected joint
Barlow Maneuver & Ortolani Maneuver
Hip Exam for Hip Dysplasia in the newborn
Done with the Ortolani maneuver (Abducted in a frog-leg position)
Barlow Maneuver Flex hip and knees to 90 degrees (Straight down)
Positive: Palpable and audible clunk as the head slips back into the socket
Older Adults you inspect for:
•Inspect
- Dorsal kyphosis
- Base of support broader (feet more widely spaced)
- Reduction in total muscle mass
Osteoporosis
- Osteoporosis
- Disease in which a decrease in bone mass occurs because bone resorption is more rapid than bone deposition
- Familial predisposition
- More common in Caucasians and Asians than in African Americans and Hispanics
- Symptoms: Asymptomatic
- Spontaneous fracture
- Thoracic kyphosis, poor balance, deconditioning
- Loss of height
Osteopenia:
•midway point to osteoporosis; the bone density is lower than normal but not as severe
Central Nervous System
Main network of coordination and control for the body
Brain
Spinal Cord
Peripheral Nervous System
Carries information to and from the CNS
Cranial nerves
Spinal nerves
Autonomic nervous system
Coordinates and regulates the internal organs of the body
Two divisions that balance the impulses of each other are the:
Sympathetic division and Parasympathetic division
Sympathetic division of the nervous system does what?
•Sympathetic division: prods body to action during periods of physiologic and psychologic stress
Parasympathetic division of the nervous system does what?
•Parasympathetic division: functions in a complementary and counterbalancing manner to conserve body resources and day-to-day functions (e.g., digestion and eliminations)
The brain and spinal cord are protected by:
- Skull and vertebrae
- Meninges
- Cerebrospinal fluid (CSF)
What do the three layers of the meninges do?
•Three layers of meninges produce and drain CSF
What does CSF do and where is it?
•CSF circulates between an interconnecting system of ventricles in the brain and around the brain and spinal cord, serving as a shock absorber
Three major units of the brain
- Cerebrum
- Cerebellum
- Brainstem
What does the gray outer layer (cerebral cortex) house and is responsible for?
•Gray outer layer (cerebral cortex) houses the higher mental functions and is responsible for:
- General movement
- Visceral functions
- Perception
- Behavior
- Integration of functions
Functions of the Brainstem
- Pathway between the cerebral cortex and the spinal cord
- Controls many involuntary functions
- The nuclei of the 12 cranial nerves arise from these structures
How many peripheral nerves originate from the brain and what are their functions?
KNOW THE PICTURE
- Twelve peripheral nerves that originate from brain
- Functions
- •Motor
- •Sensory
- •Parasympathetic
Gray matter on the spinal cord contains?
Nerve cell bodies
Spinal cord begins as a continuation of the…
medulla oblongata
Myelin coated white matter in the spinal cord contain….
Ascending and descending tracts
The spinal cord extends from the _______ to ______
and contains _____ and ______ pathways that exit and enter the cord via ______ and ______ nerve roots and ______ and ______ nerves
•The spinal cord
- •Extends from brainstem (medulla) to L1-L2 vertebrae
- •Contains motor and sensory pathways that exit and enter the cord via anterior and posterior nerve roots and spinal and peripheral nerves
5 segments of the spinal cord
•5 segments: cervical (C1-8), thoracic (T1-12), lumbar (L1-5), sacral (S1-5), coccygeal
Cauda equina
Cauda equina at L1-2, where nerve roots fan out like a horse’s tail
Spinal Nerves
- Thirty-one pairs arise from the spinal cord
- Exit at each intervertebral foramen
- Sensory and motor fibers of each spinal nerve supply receive information in a specific body distribution called a dermatome
Within the spinal cord each spinal nerve separates into anterior and posterior roots
Motor or efferent fibers of the anterior root carry impulses…
Sensory or afferent fibers of the posterior root carry impulses…
- Motor or efferent fibers of the anterior root carry impulses from the spinal cord to the muscles and glands of the body
- Sensory or afferent fibers of the posterior root carry impulses from sensory receptors of the body to the spinal cord, and then on to the brain for interpretation by the cerebral sensory cortex
What are the primitive reflexes present in the newborn?
Moro (startle reflex), stepping, palmar and plantar grasp
At birth, the neurologic impulses are primarily handled by the
•At birth, the neurologic impulses are primarily handled by the brainstem and spinal cord
Motor maturation is in cephalocaudal direction
Cephalocaudal (head to toe direction)
- Head and neck
- Trunk
- Extremities
Older adults and the CNS
- The number of cerebral neurons decreases with aging, but this is not necessarily associated with deteriorating mental function
- Vast number of reserve neurons inhibits the appearance of clinical signs
- Velocity of nerve impulse conduction declines
- •Slowed response time
- •Diminished touch and pain perception
- •Diminished functions of smell, taste and vision
•Normal aging changes increase risk for abnormal findings
- •Unsteady gait, increase risk of fall
- •Decrease Range of motion
- •Diminished appetite
Vertigo
Vertigo
Chief complaint - Spinning or sensation of self motion
Triggering event - Acute asymmetry of vestibular system. Turning over in bed. Looking up to self. Moving the head
Associated symptoms and important historical features - CNS signs or symptoms: dysarthria, headache, diplopia, ataxia, neck pain. Auditory symptoms: hearing loss, tinnitus. Ataxic duration. Nausea, vomiting, unbalanced, oscillation
Key physical exam findings
- Cranial nerve exam
- Gait
- Finger to nose exam
- HINTS plus exam
Near Syncope
Chief complaint - Sense of impending loss of consciousness
Triggering event - Orthostatic hypotension upon standing. Reduced cerebral blood flow, decrease cardiac output
Associated symptoms and important historical features -
- Tunnel vision
- Palpitation
- Perspiration, pallor
- “Almost blacking out” or “almost fainting”
Key physical exam findings
- Orthostatic Blood pressure and pulse
- Cardiac exam for murmur, JVD or S3
Dysequilibrium
Chief complaint - Unstable while seated, standing or walking
Triggering event - Dizziness while Walking
Associated symptoms and important historical features -
- Multi sensory deficit, periphral
- Neuropathy
- Visual problem
- medication
Key physical exam findings
- Gait
- Romberg
- Position sense
- Sensation
- Cranial nerve exam
- Finger to nose exam
Light Headedness
Chief complaint - Floating, vague, unclear sensation of falling
Triggering event - Stress, anxiety, depression, or panic disorder
Associated symptoms and important historical features - Multiple somatic complaints. Feeling down or hopeless
Key physical exam findings
Dizziness red flags
- Abnormal vital signs
- Hemodynamically unstable
- Confusion/Impaired mental status
- Associated pain
- Neurological symptoms
- New headache, Diplopia, dysarthria, dysphasia, drop attack, unilateral weakness
- Cardiovascular symptoms (chest pain, dyspnea, syncope)
- vomiting
- Fever
- Ataxia (abnormal movement/gait)
CAN THERE BE A BLEED SOMEWHERE
Practical Approach to Dizziness
TITRATE
TIming TRiggering Target Examination
Dizziness Algorithm
Vertigo is dizzyness within
Dizzyness is room spinning
KNOW THIS ALGORHYTHM
HINTS Exam
Tremor Algorithm
Dix-hallpike maneuver
Determines vertigo and nystagmus
- Results
- Positive:
- “down” side produces nystagmus and trigger dizziness and is the side causing the positional vertigo
- If the right side is being tested (in the “down” position), the eye will rotate in a counterclockwise manner during the rapid phase of nystagmus, with a minor up-beating vertical (toward the forehead) component
- If the left side is being tested, the results are similar except the eye rotates clockwise
- Negative:
- No nystagmus is noted
Action Tremor
Occurs with voluntary contraction of muscle
Includes postural, isometric and kinetic tremors
Postural Action Tremor
Occurs with any form of voluntary movement
Includes essential physiologic, cerebellar, dystonic and drug-induced tremors
Kinetic Action Tremor
Occurs with any form of voluntary movement
Includes classic essential, cerebellar, dystonic, and drug-induced tremors
Intention Action Tremor
Subtype of kinetic tremor amplified as the target is reached
Presence of this type of tremor implies that there is a disturbance of the cerebellum or its pathways
Rest Tremor
Occurs in a body part that is relaxed and completely supported against gravity
Most commonly caused by parkinsonism, but may also occur in severe essential tremors
Olfactory (I)
SENSORY
Brain Pathway: Mucous membrane of nose to olfactory bulbs
Olfactory receptors for sense of smell
Optic II
SENSORY
Brain Pathway: II Retina -> optic nerve -> thalamus -> occipital lobe
Retina for sense of sight
Oculomotor III
MOTOR
Brain Pathway: Midbrain -> eye and eyelid
Eye muscles (including eyelids and lens); pupil (parasympathetic division)
Trochlear IV
MOTOR
Brain Pathway: Midbrain -> eye
Eye muscles
Trigeminal V
MIXED - SENSORY & MOTOR
Brain Pathway: V
Sensory: Teeth, eye, skin, tongue -> pons
Motor: Pons -> jaw muscles
Transmits nerve impulses to the teeth, eyes, skin, and tongue
Abducens (VI)
MOTOR
Brain Pathway: VI: Pons -> eye
Eye muscles
Facial (VII)
MIXED - SENSORY & MOTOR
Brain Pathway: VII
Sensory: Tongue -> pons. Taste buds on the anterior tongue.
Motor: Pons -> facial muscles, Salivary glands, tear glands
Vestibulocochlear (VIII)
aka Acoustic
SENSORY
Brain Pathway: Inner ear -> pons and medulla
Inner ear for sense of balance and hearing
Glossopharyngeal (IX)
MIXED SENSORY & MOTOR
Brain Pathway: (IX) Sensory: Tongue, throat -> pons.
Motor: Pons -> Salvary gland, Throat muscles. Pharyngeal muscles (swallowing), salivary glands
Vagus (X)
X - MIXED - SENSORY - MOTOR
Brain Pathway: X Sensory: Eardrum, ear canal, throat, heart, lungs, abdominal organs -> medulla
Internal organs, external ear canal, ear drum, and back of throat
Motor: Medulla -> throat and larynx , heart, lungs, abdominal organs
Spinal Accessory (XI)
XI - Motor
Brain pathway: Medulla -> throat and larynx, heart, lungs, abdominal organs
Internal organs (parasympathetic division), throat muscles (somatic motor division)
Hypoglossal (XII)
MOTOR XII
Brain Pathway: Medulla -> tongue muscles
Tongue muscles
Optic (CN II) Sensory and visual acuity
on FINAL
Test for visual acuity
Test for visual fields
Sensory component of the pupillary reflex
ONLY SENSORY
Visual Acuity : Central Vision
To examine CN II and ocular fx
•Position yourself in front of the patient.
Test the patient’s visual acuity, each eye separately covering one at a time.
•Snellen’s chart. Visual acuity is recorded as a fraction. The numerator indicates the distance (in feet) from the chart which the subject can read the line.
The denominator indicates the distance at which a normal eye can read the line. Normal vision is 20/20.
How to perform Rosembaum test:
Rosembaum: pocket screener is used at the bedside. Hold the pocket screener at a distance of 12-14 inches. At this distance the letters are equivalent to those on Snellen’s chart.
Vision field by CONFRONTATION
•By confrontation
- •Position yourself in front of the patient.
- •The nose normally cuts off the medial field of vision.
- •Hence, compare the patient’s right eye to your left eye and vice versa.
- •Instruct the patient to look straight at you and not to move their eyes.
- •Compare your field of vision with the subject’s.
- •Bring your finger from the right field of vision until it is recognized.
- •Test one quadrant at a time.
- •Wiggle your fingers to see whether the patient can recognize the movement.
- •Some like to have the patient count fingers, i.e., 1, 2 or 5.
- •Test all four quadrants in a similar fashion.
- •When abnormality is detected , would require automated methods of testing in the lab
Pupils: Reaction to light
CN II, III, and mid-brain connections
- Have the patient look at a distant object
- Look at size, shape and symmetry of pupils.
- Shine a light into each eye and observe constriction of pupil.
- Flash a light on one pupil and watch it contract briskly.
- Flash the light again and watch the opposite pupil constrict (consensual reflex).
- Repeat this procedure on the opposite eye.
- Normal:
- Pupil size is 3-5 mm in diameter.
- They react briskly to light.
- Both pupils constrict consensually.
Extraocular Eye Movements
CN III, IV, VI
- •Note the alignment of the eyes at rest.
- •Ductions: Movement of one eye at a time
- •Versions: Both eye movement
- •Have the patient follow an object into each of the nine cardinal fields of gaze.
- •Note that both eyes move together into each field.
- •Eye movements should be smooth and without jerking.
- •Eyelids should be gently lifted up by the examiner’s fingers when testing downward gaze.
- •Jerky, oscillatory eye movements (nystagmus) may be abnormal, especially if sustained or asymmetrical.
Ductions
Movement of one eye at a time
Versions
Both eye movement
Trigeminal
CN V
Corneal reflex
•Corneal reflex: patient looks up and away.
- Touch cotton wool to other side.
- Look for blink in both eyes, ask if can sense it.
- Repeat other side tests V sensory, VII moto
•Facial sensation: sterile sharp item on forehead, cheek, jaw.
- Repeat with dull object. Ask to report sharp or dull.
- If abnormal, then temperature [heated/ water-cooled tuning fork], light touch [cotton].
•Motor: pt opens mouth, clenches teeth.
- Palpate temporal, masseter muscles as they clench.
Motor Function: Facial muscle
CN VII
Raise eyebrows
Tightly close eyes
Puff out cheeks
Show teeth
Bell’s Palsy
Facial asymmetry
Inability to close eyelid
Drooping of the mouth
Facial nerve
Absence of NL fold
Absence of other neurological deficits such s/s of stroke
Causes of Bell’s Palsy
Often linked to exposure to a viral infection. Same viruses that cause;
cold sores and genital herpes (herpes simplex)
Chickenpox and shingles (herpes zoster)
Mononucleosis (Epstein-Barr)
Cytomegalovirus infections
Respiratory illnesses (Adenovirus)
German measles (Rubella)
Mumps (mumps virus)
Flu (Influenza B)
Hand foot and mouth disease (coxsackievirus)
CN VIII
HEARING
GLOSSOPHARYNGEAL
CN IX
MIXED
Taste & Swallowing
Test tongue for sour and bitter
Test gag reflex and swallow
VAGUS
CN X
MIXED
Swallowing & Speech
- Inspect palate and uvula for symmetry
- Inspect for swallowing difficulty
- Evaluate guttural speech sounds
CN XI
Trapezius and Sternocleidomastoid muscles
- Have patient shrug shoulder against resistance and evaluate strength of Trapezius muscle.
- Have patient turn head to one side against resistance and evaluate strength and observe contracting sternomastoid muscle
CN XII
Tongue Movement
This nerve tests the bulk and power of the tongue.
Tongue will deviate toward the lesion of the brain
How to document CN assessment
CN II - XII grossly intact
CN I
Olfactory
Smell
Odor recognition
CN II
Optic
Visual acuity
Visual fields
CN III
Oculomotor
Raise eyebrows
Extraocular eye movements
CN IV
Trochlear
Eye movement - inward and downward
CN V
Trigeminal
Chewing
Clenching teeth
Sensations on forehead
CN VI
Abducens
Lateral eye movements
CN VII
Facial
Facial expressions
Taste - anterior 2/3 of tongue
Secretion tears and saliva
CN VIII
Acoustic
Hearing
Equilibrium
CN IX
Glossopharyngeal
Swallowing
Gag reflex
Taste - posterior third of the tongue
Salivary gland secretion
CN X
Vagus
Speech phonation
Swallowing
Sensation behind ear
Gag reflex
XI
Spinal Accessory
Turn head
Shrug shoulders
XIII
Hypoglossal
Tongue movement
The Romberg Test
Patient stands with feet together and eyes open, then with the eyes closed for 30 - 60 seconds without support
Loss of balance when eyes closed is a positive test
The pronator drift
- patient to stand for 20 to 30 seconds with eyes closed and both arms straight forward with palms up
- clinician taps the arms briskly downward. The arms normally return smoothly to the horizontal position,
- loss of position strength, arms will drift sideward or upward, which is a positive test for pronator drift
How to access a patients gait
•Gait – assess gait as patient:
- Walks across room
- Walks heel-to-toe
- Walks on toes then heels
- Hops in place
Heel to toe coordination testing
•Assess proprioceptive system including cerebellar function
How to test for Sensory Function
•Superficial/light touch
- Cotton wisp or fingertip
•Superficial pain
- Broken tongue blade or the point and hub of a sterile needle
•Temperature
- Tested only when superficial pain sensation is not intact
•Vibration
- Tuning fork (lower Hz)
•Proprioception sensory function
- Position of joints
- Raise or lower
Monofilament test
- Sensory test to evaluate diabetic and peripheral neuropathy
- Testing with a 5.07 monofilament should be done on several sites
- the patient’s eyes closed, the clinician places the monofilament on several sites of the plantar surface of each foot and one side of the dorsal surface of the foot in a random pattern
- pressure for 1.5 seconds to each site
- Testing is positive if the patient cannot feel the monofilament indicative of peripheral neuropathy
Cortical Sensory Function
- Test cognitive ability to interpret sensations
- Inability to perform these tests should make you suspect a lesion in:
- •Sensory cortex
- •Posterior columns of the spinal cord
•The primary sensory functions must be intact to perform cortical sensory function
- •Always check if primary sensory functions are intact, first
Stereognosis
(Cortical Sensory Function)
Familiar object (key, coin)
Graphesthesia
Ability to recognize numbers, symbol
Letter traced on the palm
Tactile Agnosia
An inability to recognize objects by touch, suggests a parietal lobe lesion
Cortical Sensory Function
Eyes closed
•Point location
- •Touch an area on the patient’s skin and withdraw the stimulus
- •Ask the patient to point to the location you lightly touched
- •Prefered test by provider (quick)
•Two-point discrimination
- •Distance at which the patient can no longer distinguish two points
- •Varies with body parts
•Extinction phenomenon
- •Simultaneously touch two areas on each side of the body
- •Similar sensations should be felt bilaterally
- •Patient should be able to discriminate the number of touches
Deep Tendon Reflexes
General Principles
- Select a properly weighted hammer
- Encourage the patient to relax;
- Hold the reflex hammer loosely
- brisk direct movement; use the minimum force needed to obtain a response
- Use reinforcement when needed
- Grade the response 0-4+
List the Superficial Reflexes
Plantar reflex
Abdomen reflexes
Cremaster reflex
Anal wink
How to perform the Plantar Reflex
- Stroke the lateral side of the foot from the heel to the ball and then curve across the ball of the foot to the medial side
- Patient should have plantarflexion of all toes
- Babinski sign is present when there is dorsiflexion of the great toe
- Indicates pyramidal tract disease
Location of tendons for evaluation of deep tendon reflexes
A, Biceps. B, Brachioradial. C, Triceps. D, Patellar. E, Achilles. F, Evaluation of ankle clonus.
How do you perform a Biceps - deep tendon reflex
1- Have the patient’s elbow at about a 90° angle of flexion with the arm slightly bent down as shown in figure 2-6.
2- Grasp the elbow with your left hand so the fingers are behind the elbow and your abductee thumb presses the biceps brachial tendon.
3- Strike your thumb a series of blows with the rubber hammer, varying your thumb pressure with each blow until the most satisfactory response is obtained.
4- Normal reflex is elbow flexion (bending)
How do you perform a Triceps - deep tendon reflex
- Grasp the patient’s wrist with your left hand and pull his arm across his chest so the elbow is flexed about 90° and the forearm is partially bent down.
- Tap the triceps brachial tendon directly above the olecranon process. The normal response is elbow extension.
How to perform Brachioradialis Reflex
- Strike the brachioradialis tendon on the lateral side of the forearm
- Apply your finger over the area and strike the hammer on your finger
- Mild supination of the hand, wrist extension and flexion of the elbow
How to perform the Achilles reflex : ankle jerk
- Tap the Achilles tendon and the foot should extend from the contraction of the gastrocnemius and soleus muscles responding to that tap. Perform the reflex test in this manner:
- Have the patient sit on a table or bed so that his legs dangle.
- With your left hand, grasp the patient’s foot and pull it in dorsiflexion (upward). Find the degree of stretching upward of the Achilles tendon that produces the optimal response.
- Tap the tendon directly.
- Normal response is contraction of the gastrocnemius and plantar flexion of the foot.
Deep tendon reflexed with cord levels for each response to help localize any abnormalities
- Biceps reflex (C5-6)
- Brachioradial (C5-6)
- Triceps reflex (C6-8)
- Supinator or brachioradialis (C5-6)
- Patellar reflex (L2-4) (May need interlocking hands to distract)
- Ankle reflex (primarily S1-and L5) Please correct
- Clonus, a hyperactive response required for assigning a reflex grade of 4, usually elicited at the ankle
- Superficial reflex
- Cremasteric (T12; L1-2)
- Plantar (L5; S1-2)
Meningeal Sign
Neck mobility
Brudzinski’s sign
Kernig’s sign
Brudzinski sign
•Severe neck stiffness causes a patient’s hips and knees to flex when the neck is flexed.
Kernig’s sign
•Severe stiffness of the hamstrings and inability to straighten the leg when the hip is flexed to 90 degrees
Decorticate Posturing
Legs and feet extended with plantar flexion and arms rotated and flexed on chest.
Decorticate posture may progress to decerebrate posture, or the two may alternate. The posturing may occur on one or both sides of the body.
Decerebrate posturing
Arms stiffly extended and hands turned outward and flexed, leg also extended with plantar flexion
Decorticate posture may progress to decerebrate posture, or the two may alternate. The posturing may occur on one or both sides of the body.
What are Static disorders of the central and peripheral nervous system?
•Static problems develop at any age and do not get better or worse (e.g., nerve deafness and some trauma)
What are Degenerative disorders of the central and peripheral nervous system?
•Degenerative problems occur when function is lost and it progressively worsens
What is Multiple Sclerosis
- Multiple sclerosis
- Progressive autoimmune disorder characterized by a combination of inflammation and degeneration of the myelin of the brain’s white matter leading to decreased brain mass and obstructed transmission of nerve impulses
How does MS progress?
•Gradual, but unpredictable, progression, with or without remissions
What are the physical side effects of MS
•Physical:
- Weakness
- Gait disturbance
- Foot drop
- Hyperesthesia or paresthesia
- Cerebellar dysarthria (scanning speech)
- Spasticity (especially in lower extremities)
- Positive clonus, Babinski.
What are Seizure disorders and what are they caused by?
•Episodic abnormal electrical discharges (excessive concurrent firing) of cerebral neurons may be caused by:
- CNS disorder
- CNS structural defect
- Disorder that affects functioning of the CNS
•Examples include brain injury, toxins, stroke, brain tumor, or hypoxic syndromes
What is a stroke and what are the two types of stroke?
- Stroke (brain attack or cerebrovascular accident)
- Sudden interruption of blood supply to a part of the brain or the rupture of a blood vessel, spilling blood into spaces around brain cells
- Ischemic
- Hemorrhagic
What is Myasthenia Gravis
•Myasthenia gravis is a Peripheral Nervous System disease
- •Autoimmune disorder of neuromuscular transmission
- •Usually proximal to distal progression
What is the hallmark of MG
Fatigability
What are the physical side effect of MG?
- Fluctuating weakness, often subtle, that worsens during the day and after prolonged use of affected muscles, may improve with rest
- Early symptoms are transient with asymptomatic periods lasting days or weeks.
- >50% of patients present with ocular symptoms (ptosis and/or diplopia). Eventually, 90% of patients with MG develop ocular symptoms.
- Ptosis might be unilateral, bilateral, or shifting from eye to eye.
What is Guillain-Barre Syndrome
•Autoimmune-mediated destruction of peripheral nerve myelin sheaths and inflammation of nerve roots
What are the characteristics of Guillain-Barre syndrome
- Occurs following a nonspecific gastrointestinal or upper respiratory infection 1 to 3 weeks earlier or following an immunization
- Distal to proximal progression
- Typical features are distal sensory changes followed by progressive motor weakness and areflexia.
Physical characteristics of Guillain Barre syndrome
- unsteady gait which may be due to sensory ataxia, facial weakness, diplopia, leg or back pain, or sensory changes in the extremities.
- Paresthesia and pain typically occur in a stocking/glove distribution, frequently early in the course.
- Most patients first note leg weakness or gait instability that progresses over days to weeks. 60% are unable to walk at the peak of symptoms.
- Characteristic findings include muscular weakness and sensory changes, most often symmetric with distal greater than proximal involvement
What is Trigeminal neuralgia (tic douloureux)
•Recurrent paroxysmal sharp pain that radiates into one or more branches of the fifth cranial nerve
Peripheral neuropathy
•Disorder of the peripheral nervous system that results in motor and sensory loss in the distribution of one or more nerves
- Diabetes mellitus
- B12 deficiency
- Lyme disease
- HIV infection
What is Cerebral Palsy?
•Permanent non-progressive (adult stage) disorder of movement and posture development
Physical presentation of CP
- Assess for more than one type of neurologic impairment:
- Spasticity: increased tone/reflexes/clonus
- Dyskinesia: abnormal movements
- Hypotonia: decreased tone
- Ataxia: abnormal balance/coordination
A clinical diagnosis of CP includes
- Delayed motor milestones
- Abnormal tone
- Abnormal neurologic exam suggesting a cerebral etiology for motor dysfunction
- Absence of regression (not losing function)
- Absence of underlying syndromes or alternative explanation for etiology
What is Myelomeningocele (spina-bifida)
•Congenital defect of one or more vertebrae (commonly the lumbar or sacral) that permits a meningeal sac filled with a portion of the spinal cord to protrude
How do you best prevent Spina Bifida
- Best prevented by taking a daily dose of folic acid
- As soon as you suspect pregnancy before confirming it, please, please start the mother on folic acid 400 mg po daily
Shaken baby syndrome
- Severe form of child abuse resulting from the violent shaking of infants under 1 year of age
- Stretching and tearing of nerve tissue and blood vessels causes brain damage and a subdural hematoma
- Spinal cord may also be damaged
What are the characteristics of Parkinson disease
- Slowly progressive, degenerative neurologic disorder
- Deficiency of the dopamine neurotransmitter results in poor communication between parts of the brain that coordinate and control movement and balance
What is the first sign of Parkinsons disease
•First signs usually a mild resting tremor unilateral presentation
A complete neurological assessment includes
A complete neurological assessment consists of :
- Cranial nerves
- Proprioception (feeling and self in space and balance) and cerebellar function
- Sensory function
- Reflex function
CN II
No motor component
See the light
CN III
Motor component
Pupil constricts
Trigeminal neuralgia
aka
Tic Douloureux
A condition affecting the largest nerve in the face that provides sensation. Only sensory not motor. Described as the worst pain known to mankind.
What is a tell-tell sign of Bell’s Palsy and what precedes it?
Loss of NL fold and a respiratory illness precedes it
CN IX
The fact they can feel the stick in the back of the throat and the raising of the uvula
CNX
Swallowing
Proproception
Sense of self in space and gait.
•Abstract thinking develops:
- Ability to develop theories
- Ability to use logical reasoning
- Ability to make future plans
- Ability to use generalizations
- Ability to consider risks and possibilities
Judgment begins to develop with
education, intelligence, and experience.
HEADSS assessment
HEADSS assessment
(Home, Education/Employment, Activities, Drugs, Sexuality, Suicide)
Cognitive function should be intact in the healthy older adult, but declines in cognitive abilities occur in some older adults after
60 or 70 years of age.
Speed of information processing and psychomotor speed begin declining at a modest rate after
•30 years of age
Verbal skills and general knowledge continue to increase into the_____and often remain stable into the _____
•Verbal skills and general knowledge continue to increase into the 60s and often remain stable into the 80s.
In older adults recent memory is believed to deteriorate before
remote memory
- Cognitive declines in executive functioning often preceded memory loss in a recent study of highly functioning elderly women
- Plan and develop strategies
- Organize, concentrate, and remember details
- Manage activities
- The cognitive decline leading to dementia may occur over 20 to 30 years, and it may begin as early as 45 years of age in some persons.
Mnemonic for Depression SIGECAPS (associated factors to depression: oldcaArts
- S sleep disorders
- I interest (anhedonia – no interest)
- G guilt (worthlessness, regret, hopelessness)
- E energy deficit
- C concentration
- A appetite
- P psychomotor retardation or agitation(irritability)
- S suicidality
What are key questions and considerations when assessing the mental status of a patient
- Conducted within context of age, developmental level, and cultural norms
- Appearance: Affect, posture, hygiene and grooming, body habitus
- Behavior: Verbal/nonverbal expressions of pain, anxiety, emotions, interactions, activity level, body movements and mobility
- Cognition: Oriented to time, person, and place, attention and concentration, pattern and pace of speech, judgment, memory, mood
What 3 things are identified when assessing for DTS or DTO?
- Homicidal ideation (HI)
- Suicidal ideation (SI)
- Identify protective factors
If there is a DD of mental health you have to ask about suicidal ideations
Mneumonic for Depression SIGECAPS
assoc factors to depression
- S sleep disorders
- I interest (anhedonia – no interest)
- G guilt (worthlessness, regret, hopelessness)
- E energy deficit
- C concentration
- A appetite
- P psychomotor retardation or agitation(irritability)
- S suicidality
- Must have experienced at least five of the symptoms for the previous two weeks to be diagnosed with a MDD!!!!
PHQ2
LOOKS AT SX IN THE PAST 2 WEEKS
START LOOKING AT INTERVENTIONS AT A SCORE OF 10
Assess mental health during the general survey or if there is a past medical history
What are some Differential diagnoses for someone presenting with depression
- Mental health conditions:
- Depression
- Depressed phase of bipolar disorder—inquire if prior mania, family or personal history of bipolar disorder, prior agitation, or excitement with antidepressant medication.
- Adjustment disorder with depressed mood
- Substance abuse-related mood disorders
- Medical comorbidity: adrenal diseases, anemia, hypothyroidism, diabetes, hypercalcemia, liver or renal failure, malignancy, sleep disorders, chronic fatigue syndrome, fibromyalgia, lupus
- Neurologic or cognitive disorders such as neurodegenerative CNS disease, dementia, or delirium
- Deficiencies: vitamin B3, Vitamin D, vitamin B12, or folate
What is SAFE-T
Suicide Assessment Five-step Evaluation and Triage
- Identify risk factors
- Identify protective factors
- Conduct suicide inquiry
- Determine risk level/intervention
- Document
What are some suicide risk factors?
Psychic pain/anxiety
Psychiatric diagnosis; Prior Suicide attempt
Agitation; Comorbidity; Firearm access;
Hopelessness
HPI: Anxiety GAD - 7
SCORE OF 10 REQUIRE INTERVENTION
Name two screening tests to access cognition
Mini-Mental State Examination (MMSE) - most studied
Mini-Cog - three unrelated words, clock face
Mini-Mental State Examination MMSE
Anyone over 65 should have one
A score up to 24 is NORMAL
Score of 20 is MILD
Mini-Cog Screening
1- Get your patient’s attention and have them repeat 3 unrelated words to you. You may repeat words up to 3 times to make sure patient has register each one.
Leader, season, table.
2- Ask the patient to draw a clock face with all the numbers on it then and set the time at 10 past 11. You may repeat instructions as needed.
If patient cannot complete the clock in 3 minutes (score zero) and move to the next step
2 points if correct, with all numbers inside the circle, right sequence and right time. And Zero point if incorrect
3- Recall 3 words.
1 point for each word correctly recalled
Interpretation:
0-2 = positive screen
3-5 = negative screen but does not rule out completely cognitive impairment
A score of 3 or less: patient needs to be evaluated further.
Catatonia:
Catatonia: group of symptoms that usually involve a lack of movement and communication, and also can include agitation, confusion, and restlessness. Often present in schizophrenic patients – talking to a statue then super agitated
Akathisia
Akathisia (Greek “not to sit”) is an extrapyramidal movement disorder consisting of difficulty in staying still and a subjective sense of restlessness.
Pressured speech
Pressured speech: characterized by rapid, compulsive talking, is a classic symptom of hypomanic and manic episodes in people with bipolar.
Apathetic:
Apathetic:
- stop caring about everyday tasks, hobbies, or personal interests
- struggle to show interest and enthusiasm in others
- feel indifferent to spending time with others
- experience very little emotion or changes in mood
Elated mood
Elated mood: state of heightened joy, exaggerated optimism, and restless excitement. Indicative: drug induced, schizophrenia, psychosis, mania.
Labile mood:
Labile mood: characterized by sudden, rapid changes in mood not congruent to the stimuli.
What algorithm do you reference for Suicidal Ideations?
SAFE-T
Concrete thinking:
Concrete thinking: “cognition that reflects experience, rather than abstraction, typical of those who are unable to generalize.” AKA literal thinking
Circumstantial thought:
Circumstantial thought: the use of many words where fewer would do AKA Circumstantiality: speech characterized by indirection
and delay due to the patient’s excessive use of details
that have no connection to the point
Tangentiality:
Tangentiality: phenomenon in which a person constantly digresses to random, irrelevant ideas and topics, never answering the original questions.
Loose associations AKA Derailment:
Loose associations AKA Derailment: a person shifts topics with no apparent relation between the topics, The frame of reference often changes from one sentence to the next. Thought derailment is a symptom of schizophrenia
Echolalia
Echolalia: repeat noises and words they hear instead of expressing their thoughts. For example, instead of answering a question, they may repeat the question.
Flight of ideas
Flight of ideas: similar to derailment but much faster in speed, close to manic. “people to speak rapidly and quickly shift between loosely connected ideas when speaking. Speech is pressured, quick, at time incoherent, speak so fast they may slured their speech, but for them, they make complete sense. Schizophrenia.
Perseveration
Perseveration: persistent repetition of words or ideas even when another person attempts to change the topic. Talking about a grievance over and over, and won’t stop even when provider wish to change the subject. common symptom of early Alzheimer’s disease
Clangassociation
Clangassociation : speech in which word choice is governed by word sound rather than meaning; word choice may show rhyming or punning associations. Example: He rained the train brain strain gain the crane.”. Bipolar, schizophrenia,
Blocking
Blocking: interruption of speech while ostensibly in pursuit of a goal
Word salad:
•Word salad: Incoherence (word salad, schizaphasia): severe lack of speech cohesion at the basic level of syntax and/or semantics within sentences. Advanced Schizophrenia. Example” Run desk making dinner sunglasses menu”
Magical thinking/delusion:
Magical thinking/delusion: similar: the belief that one’s ideas, thoughts, actions, words, or use of symbols can influence the course of events in the material world. Magical thinking presumes a causal link between one’s inner, personal experience and the external physical world.
Poverty of speech:
Poverty of speech: a common symptom of schizophrenia, and may co-occur with poverty of content – assoc depression
Neologism
Neologism: the creation of new “words”
Illusion
Illusion: misinterpretation of a correct sensory input. For example, a child who perceives tree branches at night as if they are monsters.
Impulse control disorders:
Impulse control disorders: condition in which a person has trouble controlling emotions or behaviors. Often, the behaviors violate the rights of others or conflict with societal norms and the law.
Judgement
Judgement: The ability to make considered decisions or come to sensible conclusions. “what would you do if you saw a fire in a movie theater?”
Insights
Insights: the capacity to gain an accurate and deep intuitive understanding of a person, situation, event.
Concussion
•Rotational forces cause a transient disruption in the reticular neurons that maintain alertness
- Sports injuries
- Motor vehicle accidents
- Falls
Delirium
- Impaired cognition, consciousness, mood, and behavioral dysfunction of acute onset
- Risk factors
- Serious illness
- Injury
- Preexisting cognitive decline
Fluctuating mental health
•Delirium tremens
•Brain’s response to withdrawal from alcohol consumed in large quantities over time•
Delirium tremens signs include agitation, confusion, combativeness, panic, seizures, hallucinations, and illusions
•Depression
- Common psychiatric disorder associated with a neurochemical imbalance
- Symptoms from mild to major depressive disorder are characterized by feelings of helplessness and hopelessness and recurrent suicidal thoughts
Mania
- Persistently elevated, expansive, or irritable mood lasting longer than 1 week, one phase of the bipolar disorder
- Associated with a neurochemical imbalance, an increased level of monoamines
•Anxiety disorder
•Group of disorders with such marked anxiety or fear that it causes significant interference with personal, social, and occupational functioning
Associated with abnormalities in the norepinephrine and serotonin systems
•Schizophrenia
(Mood Disorder)
- Schizophrenia
- A severe, persistent, psychotic disorder with relapses throughout life
- May be associated with fetal neurodevelopmental defects:
- Viral infection during pregnancy
- Prenatal nutritional deficits
- Perinatal complications
How to diagnose Schizophrenia
DSM 5: Two or more of the characteristic symptoms below are present for a significant portion of time during a one-month period (or less if successfully treated):
- •1. Delusions
- •2. Hallucinations
- •3. Disorganized speech (eg, frequent derailment or incoherence)
- •4. Grossly disorganized or catatonic behavior
- •5. Negative symptoms, ie, affective flattening, alogia, or avolition
•Attention-deficit/hyperactivity disorder (ADHD)
- A neurobehavioral problem of impaired attention and hyperactive behavior affecting 5% to 10% of school-age children
- Theorized that dopamine system disturbances may be associated with ADHD onset
Dementia
•A chronic, slowly progressive disorder of:
- •Failing memory
- •Cognitive impairment
- •Behavioral abnormalities
- •Personality changes
- Often begins after 60 years of age
- Usually related to structural diseases of the brain
Alzheimer type dementia
- Approximately 60% of cases
- May be caused by abnormal processing or deposition of amyloid
•Vascular dementia
- Approximately 5% to 10% of cases
- Reduced cerebral blood flow such as a brain infarct(s)
•Other dementias
- Associated with diffuse Lewy bodies in the brain
- Parkinson disease
- Frontal lobe degeneration AKA Pick’s dementia
What part of the brain is most at risk with substance use disorder esp in teens
- Prefrontal cortex: Responsible for complex cognitive processes and not fully mature until young adulthood
- Adolescents have increased vulnerability to substance use disorder
When do you assess for potential substance abuse?
- Routine: rapid screen for Tobacco, ETOH, and drug abuse
- Patient presents with specific complaints
- Patient is seeking highly addictive medications
- Patient admits with s/s of drug abuse, withdrawal.
SBIRT Model
- Step one: In social history
- Rapid screen: One question:
- Tobacco: Do you smoke-> pack/year
- ETOH: Do you drink. Yes-> how much how frequent.
- If above limit: 2 standard drinks for men, and one for women daily, rapid screen is positive ->administer appropriate screening tool
- FYI upper limit is less for senior: 1 standard drink for men or women, may drink up to 3 drink equivalent on accession not to exceed 7 drink equivalent a week
- Prescription/illicit drugs:•“How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?” Any positive answer requires further more extensive screening
Standard drink amounts
What is the legal limit for drunk driving?
If the patient weighs less than 200lbs he/she will reach BAC level after ____ standard drinks?
the legal limit for drunk driving is a blood alcohol concentration (BAC) level of 0.08.
If patient weight less than 200 pounds he/she will reach BAC level after two standard drink
Any tool you perform during the medical encounter is considered an
Objective finding (even though it is a patient report)
CAGE tool is for ______
ETOH only
CAGE AID screening tool is for: _____________
Screening CAGE AID: ETOH and other drugs
Screening Assist tool for:
All types of substance abuse
DAST 10 screening tool is for:______
Drug abuse
PHQ9 is for _____
GAD 7 is for _____
For elderly patients administer _____
- Administer PHQ9 (depression) GAD 7 for anxiety
- For elderly patient might be useful to administer MMSE or minicog
•Four processes of Motivational Interviewing relevant to advanced assessment
- Engaging: Used throughout assessments, including when resistance is encountered
- Focusing: Attention to a patient problem and goal
- Evoking: Process of evoking change talk from patients
- Planning: Guiding the individual to form a concrete plan of action
Important components of motivational interviewing are:
- Important components of MI include empathizing and empowering the individuals to take steps toward change and affirming their strengths.
- Provider must be genuine, honest, show empathy
- Provider use open-ended questions, validation and affirmation and use of reflective listening
5 A’s to Support Behavioral Change
Advise
Agree
Arrange
Assess
Assist
DSM-5
very long
•DSM-5 criteria for addiction and nonsubstance addictive behaviors
- •Assess for behaviors causing personal, emotional, social, financial, spiritual, or legal harm to individuals
Stages of change:
Time frame of 6 months for the stages
Except for Stage 3 which is 30 days
- Stage 1: Precontemplation is when an individual is not yet considering change or is unwilling or unable to change.
- Stage 2: Contemplation occurs when the possibility of change is recognized but one is ambivalent and uncertain.
•Stage 3: Preparation or Determination is the stage in which the individual is committed to changing within 30 days but is still considering what to do.
- Stage 4: Action includes taking steps toward change but the change is not yet stabilized.
- Stage 5: Maintenance is the stage in which goals have been achieved and efforts are focused on maintaining the change.
- Stage 6: Recurrence is defined as experiencing a recurrence or relapse of the old behaviors and deciding what to do next.
Skeletal changes in older adults are the result of:
Increased bone reabsorption
